Sugammadex and anaphylaxis: An analysis of 33 published cases.

In this study, the published sugammadex-induced anaphylaxis reports were reviewed to determine similarities in their presentation during anesthesia. PubMed was searched for sugammadex-induced anaphylaxis without time limitation. Reports were evaluated if they were in English and met the criteria of anaphylaxis determined by the World Allergy Organization. Two independent reviewers extracted and assessed the data using predesigned data collection forms. In total, 23 suitable articles were found and 33 sugammadex-induced anaphylaxis cases were included in the study. The mean age was 43.09 years (from 3-89 years) and 17 (51.5%) of the patients were female. Considering all reported cases, the average onset time of anaphylaxis was 3.08 min, with a median of 3 min (range 1-8 min). The most common signs and symptoms were hypotension, tachycardia, erythema, and desaturation. Of the 20 patients who underwent confirmatory skin testing, 15 had a positive skin reaction for sugammadex. Epinephrine was not given when indicated in about 25% of cases. Sugammadex-induced anaphylaxis onset time was less than 5 min in 92.3% of all the reported cases. Rapid diagnosis and early recognition of signs and symptoms of anaphylaxis are essential for a favorable prognosis. Treatment needs to be started as soon as possible to ensure the best outcome for the patient.

Kidney Transplantation and COVID-19: Two Case Reports.

Immunocompromised populations are at great risk of the current 2020 global emergency of coronavirus disease 2019 (COVID-19), and treatment of kidney transplant recipients with COVID-19 is currently not declared. Hence, the purpose of the study is to set a clear treatment regimen. We report here a therapeutic course of 2 patients who underwent transplant surgery in March 2020 and got infected soon after. Since the transplant, these 2 patients have received triple maintenance immunosuppressive therapy with oral tacrolimus, mycophenolate mofetil (MMF), and prednisone, and they have been regularly followed up at our hospital. The tacrolimus trough level was between 10 and 12 ng/mL. After the diagnosis of COVID-19, MMF was stopped and the tacrolimus dose was reduced so that blood level was between 4 and 6 ng/mL. The first patient was a 30-year-old man who, despite being treated with hydroxychloroquine, favipiravir, oseltamivir, and azithromycin therapy, died because of the presence of other comorbidities. The second case was a 58-year-old man who fully recovered from COVID-19 pneumonia with treatment with methylprednisolone, MMF, azithromycin, favipiravir, hydroxychloroquine, and reduction in immunosuppression dosage. This reflects the importance of using glucocorticoids in the treatment of COVID-19 along with other medications and the decreased mortality rate associated with their use.

Comparing local anesthetic infiltration of the peritonsillar region and glossotonsillar sulcus for post-tonsillectomy pain management.

PURPOSE: The objective of this study was to compare the efficacy of peritonsillar and glossotonsillar sulcus infiltration with bupivacaine to manage postoperative pain and odynophagia in children undergoing tonsillectomy. METHODS: Fifty children (5-10 years of age) undergoing tonsillectomy due to recurrent tonsillar infections were enrolled in the study and assigned into two groups receiving either pre-incisional peritonsillar (Group 1, n = 25) or glossotonsillar sulcus (Group 2, n = 25) infiltration with 1 mg/kg bupivacaine (0.5%) totaling 5 mL in volume. At different time intervals following arrival to the post-anesthesia care unit (PACU), the participants in each group were evaluated for pain using the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) and for odynophagia using a four-point scale (1-none, normal or no difficulty with swallowing, 2-mild, mild difficulty with swallowing, 3-moderate, moderate difficulty with swallowing, and 4-severe, no swallowing or swallowing only with maximal effort). Additional parameters were assessed for 24 h post-surgery, including time to first administration of analgesic, additional analgesic requirements, nausea/vomiting, allergic reaction, and bleeding. RESULTS: Infiltration of either region with bupivacaine yielded similar analgesic effects at different times following the surgery (P = 0.065). Time to first analgesic treatment and additional analgesic requirements were not significantly different between groups (P = 0.181). Compared to the Group 1, Group 2 was associated with significantly lower odynophagia scores at different times after the surgery (P = 0.020). CONCLUSION: Present results indicate that the infiltration of local anesthetics to glossotonsillar sulcus is a safe, practical, and effective pain management intervention without risk of significant side effects for children undergoing tonsillectomy.

The effects of maternal presence during anesthesia induction on salivary cortisol levels in children undergoing tonsillectomy and/or adenoidectomy.

OBJECTIVE: Although parental presence during anesthesia induction is suggested to diminish operative stress level in children, there have been conflicting results about this strategy. The aim of this study was to evaluate the effects of maternal presence during induction on operative stress level in children who had tonsillectomy and/or adenoidectomy by determining the salivary cortisol levels. DESIGN: Non-randomized clinical study. SETTING: Preoperative and postoperative recovery rooms, operating room. PATIENTS: The study included 48 children between the ages of 5-12years who underwent tonsillectomy and/or adenoidectomy. INTERVENTIONS: The patients were divided into 2 groups. The children in group 1 were separated from their mothers at the preparation room. The children in group 2 stayed together with their mothers till the anesthesia induction. MEASUREMENTS: State Trait Anxiety Inventory (STAI) was performed to the mothers and children preoperatively. Salivary cortisol levels were evaluated in 4 different time frames: 1) in preparation room, 2) after anesthesia induction, 3) at the 30th minute of operation, and 4) in postoperative recovery room. MAIN RESULTS: There were no statistically significant differences between groups regarding demographic features, and operation or anesthesia times. The child's or mothers' preoperative anxiety scores were not different between the groups. Salivary cortisol levels in group 1 were significantly increased after induction and in recovery room compared to those in group 2 (p: 0.001, and p: 0.02, respectively). CONCLUSIONS: We have determined decreased salivary cortisol levels during anesthesia induction and recovery in the maternal presence revealing diminished stress in these periods. Further studies are warranted to determine the effects of parental presence during anesthesia induction especially on surgical outcomes.

The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy.

STUDY OBJECTIVES: Sleeve gastrectomy has been one of the most commonly performed bariatric surgery methods. The study aimed to compare the effects of 2 most commonly used inhalation anesthetics, sevoflurane and desflurane, on the peroperative hemodynamic alterations and postoperative respiratory functions in morbidly obese patients undergoing sleeve gastrectomy. DESIGN: Nonrandomized cohort. SETTINGS: Operating room, postoperative period. PATIENTS: Eighty-four morbidly obese patients with a body mass index greater than 40 kg/m2 who had scheduled to undergo sleeve gastrectomy operation were prospectively included in the study. INTERVENTIONS: Patients were divided into 2 groups. The maintenance of inhalation anesthesia was performed by sevoflurane in 1 group (sevoflurane group) and desflurane (desflurane group) in the other group. MEASUREMENTS: Demographic features, peroperative hemodynamic alterations, and the results of preoperative and postoperative 24th hour respiratory function tests were recorded. RESULTS: There was not any statistically significant difference between groups regarding age, sex, body mass index, anesthesia time, peroperative mean arterial pressure, arterial oxygen saturation, end-tidal carbon dioxide, and preoperative or postoperative forced expiratory volume 1/forced vital capacity ratios. CONCLUSION: We determined that both desflurane and sevoflurane provide similar intraoperative hemodynamic and early postoperative respiratory functions in morbidly obese patients in laparoscopic sleeve gastrectomy. Both agents can be regarded as alternatives for inhalation anesthetics in maintenance of anesthesia.

The Syrian civil war: The experience of the Surgical Intensive Care Units.

OBJECTIVE: Since the civilian war in Syria began, thousands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and/or postoperative intensive care. The aim of this study was to present the demographics and clinical features of the wounded patients in Syrian civil war admitted to the surgical intensive care units in a tertiary care centre. METHODS: The records of 80 trauma patients admitted to the Anaesthesia, General Surgery and Neurosurgery ICUs between June 1, 2012 and July 15, 2014 were included in the study. The data were reviewed regarding the demographics, time of presentation, place of reference, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Injury Severity Score (ISS), surgical procedures, complications, length of stay and mortality. RESULTS: A total of 80 wounded patients (70 males and 10 females) with a mean age of 28.7 years were admitted to surgical ICUs. The most frequent cause of injury was gunshot injury. The mean time interval between the occurrence of injury and time of admission was 2.87 days. Mean ISS score on admission was 21, and mean APACHE II score was 15.7. APACHE II scores of non-survivors were significantly increased compared with those of survivors (P=0.001). No significant differences was found in the age, ISS, time interval before admission, length of stay in ICU, rate of surgery before or after admission. CONCLUSION: The most important factor affecting mortality in this particular trauma-ICU patient population from Syrian civil war was the physiological condition of patients on admission. Rapid transport and effective initial and on-road resuscitation are critical in decreasing the mortality rate in civil wars and military conflicts.

The predictive value of red cell distribution width levels on mortality in intensive care patients with community-acquired intra-abdominal sepsis.

BACKGROUND: Red cell distribution width (RDW) is a part of the complete blood count (CBC) panel reflecting quantitative measure of variability in the size of circulating red blood cells. It has been known that higher RDW is associated with increased mortality in several diseases. The aim of this study was to investigate the association between RDW and hospital mortality in intensive care unit (ICU) patients with community-acquired intra-abdominal sepsis (C-IAS). METHODS: A retrospective analysis of the patients with C-IAS was performed between January 1, 2010 and March 31, 2013. Patients' demographics, co-morbidities, laboratory measures including RDW on admission to the ICU, and Acute Physiologic and Chronic Health Evaluation II (APACHE II) score were analyzed. RESULTS: A total of one hundred and three patients with C-IAS were included into the study with a mean age of 64±14 years. Overall mortality was 50.5%. RDW day 1 (RDW1) values and APACHE II scores were significantly higher in non-survivors than in survivors. In multivariate analysis, only RDW1 and APACHE II predicted mortality. The area under the receiver operating curves (AUC) of RDW1 and APACHE II were 0.867 (95% CI, 0.791-0.942) and 0.943 (95% CI, 0.902-0.984), respectively. CONCLUSION: This study suggests that increased RDW is associated with mortality in ICU patients with C-IAS.

ULTRAPRO Hernia System versus lichtenstein repair in treatment of primary inguinal hernias: a prospective randomized controlled study.

The Lichtenstein repair has been recommended as the gold standard for inguinal hernia repair. However, postoperative discomfort still constitutes a concern and an area for improvement. New mesh materials have been continuously introduced to achieve this goal. The goal of the present study was to investigate the outcomes of ULTRAPRO Hernia System (UHS) compared with Lichtenstein mesh repair. A total of 99 male patients with primary unilateral inguinal hernia were included in the study during the period of September 2010-January 2012. Patients with body mass index>30, comorbid diseases, and anesthetic risk of ASA-III and ASA-IV were excluded. The patients were randomly allocated to operation with the Lichtenstein technique (group L) or UHS. Demographics, operative and postoperative/recovery data, and short- and medium-term outcomes of the patients were recorded. A total of 50 patients in group L and 49 patients in group UHS were analyzed. The median follow-up time for the study was 33 months. There were no significant differences regarding demographics, complications, and rehabilitation between the groups. Overall, there was a prolonged operation time in the UHS group compared with the L group (UHS: 53.7±5.7 minutes; L: 44.5±5.5 minutes; P<0.001). UHS may provide results similar to those for the Lichtenstein technique in open repair of inguinal hernias regarding perioperative course, complications, recovery, and recurrence rates. However, because of reduced costs and the lack of need for the exploration of the preperitoneal space, we conclude that the Lichtenstein technique should be recommended as the first choice.

Minimizing shoulder pain following laparoscopic cholecystectomy: a prospective, randomized, controlled trial.

UNLABELLED: Abstract Background: Postoperative abdominal and shoulder pains after laparoscopic cholecystectomy (LC) are the most frequent complaints and are related to delayed recovery. There is a strong correlation between the residual gas volume and the severity of pain following various laparoscopic procedures. We aimed to investigate the effects of aspiration of residual gas on postoperative outcomes and pain following LC. SUBJECTS AND METHODS: Patients were randomly assigned to either the active gas reduction group (Group 1, n=105) or the control group (Group 2, n=95). After completion of the operative procedures, residual gas was aspirated with a flexible cannula in Group 1. In Group 2, gas release from the abdomen was performed using the port site by opening the gas tap only. The demographic data, operation time, insufflated CO2 volume during the operation, hospitalization period, and time to return to daily activities were recorded. Postoperative shoulder and abdominal pain assessment was performed using a numerical pain intensity scale (NPIS) at 1 hour, 24 hours, 3 days, and 7 days postoperatively. RESULTS: There was no statistically significant difference between the groups in terms of demographic data, operative findings, and clinical outcomes. NPIS scores for shoulder pain at 1 hour and 24 hours were significantly lower in Group 1 (P=.001 and P=.021, respectively). However, there were no significant differences in the NPIS scores for shoulder and abdominal pain following 24 hours. No differences were found in the hospitalization duration and time to return to daily activities data (P>.05). CONCLUSIONS: Active aspiration of the residual gas just before the removal of the trochars is a simple procedure and leads to a more comfortable hospital stay for patients.

Methemoglobinemia presenting in a circumcised baby following application of prilocaine: a case report.

INTRODUCTION: Local anesthesia with prilocaine has become a routine part of ambulatory circumcision procedures. Methemoglobinemia is a rare but potentially lethal complication of local anesthetics. CASE PRESENTATION: We report the case of a 40-day-old Turkish boy who presented with cyanosis after receiving local anesthesia with prilocaine. His methemoglobin level revealed severe methemoglobinemia (methemoglobin = 44%). His cyanosis resolved after intravenous administration of methylene blue. CONCLUSION: Although the association between prilocaine use and methemoglobinemia has generally restricted the use of prilocaine in babies, it is still widely used in ambulatory procedures, especially during circumcision in the neonatal period. Prilocaine should not be used in babies who are less than 3 months old because of the risk of methemoglobinemia; other local anesthetics may be used for this age group. Furthermore, general anesthesia by mask ventilation may be favored for babies less than 3 months of age instead of local anesthetics.